Lumps and Bumps: The Dermatology of Lid Lesions

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1 Lumps and Bumps: The Dermatology of Lid Lesions Thomas J. Joly, MD, PhD Assistant Professor of Ophthalmology Eastern Virginia Medical School Ophthalmic Plastic Surgery Service Virginia Eye Consultants

2 Don t Miss the Forest for the Trees Goals: Raise your comfort level with benign lesions Lower your suspicion level for malignant lesions Increase your diagnostic recognition

3 Eyelid Histology Skin layers Epidermis Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basalis Basal cells Melanocytes Dermis Collagen, elastin Adnexal structures AAO (1998) Basic & Clinical Science Course

4 Eyelid Histology Terminology Acanthosis: thickened stratum spinosum Hyperkeratosis: thickened stratum corneum Parakeratosis: nuclei retained in stratum corneum Dyskeratosis: keratin deep to stratum corneum Dysplasia: Disorderly maturation of the epidermal layers or cellular atypia Hyperplasia: Rapid growth through increased cell mitosis Elastosis: degeneration of collagen due to UV exposure

5 Adnexa Hair follicle Eyelid Histology Sebaceous glands (of Zeis) Apocrine sweat glands (of Moll) Eccrine sweat glands Meibomian sebaceous glands Caruncle Conjunctiva Non-keritanized epithelium Mucus cells

6 Eyelid Histology Terminology Sudoriferous: sweat, can be apocrine or eccrine Apocrine: secretion by cellular decapitation, specialized scent glands include the glands of Moll associated with each lash Eccrine: water secretion by osmotic cellular pumps Sebaceous: oil secretion, glands include the Meibomian glands of the tarsus, glands of Zeis associated with each lash follicle, and glands in the caruncle and brow

7 Benign Neoplasia of Epithelial Origin

8 Squamous Papilloma Benign hyperplasia of epidermis in folds over fibrovascular core, possible with hyperkeratosis but with no dysplasia AAO (1998) Basic & Clinical Science Course

9 Verruca Vulgaris Squamous papilloma caused by human papillomavirus infection Intracellular viral inclusions seen on histology Concomitant conjunctivitis resolves w/ removal AAO (1998) Basic & Clinical Science Course

10 Molluscum Contagiosum Epithelial papule due to pox virus infection Typical mulluscum bodies seen on histology Concomitant follicular conjunctivitis resolves with removal FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery

11 Seborrheic Keratosis Papilloma with irregular acanthosis, variable pigmentation, and variable hyperkeratosis Appears greasy and stuck-on with sebaceous hyperplasia and accumulated desquamated keratin. AAO (1998) Basic & Clinical Science Course

12 Inverted Follicular Keratosis Papilloma with marked hyperkeratosis and acanthosis May be an inflammatory reaction of a seborrheic keratosis AAO (1998) Basic & Clinical Science Course

13 Acrochordon (fibroephithelioma, skin tag) Solitary pedunculated hyperplastic epithelium surrounding fibrovascular core Multiple skin tags associated w/ pregnancy, intestinal polyposis JA Nerad, (2001) Oculoplastic Surgery

14 Cutaneous Horn Multiple layers of hyperkeratosis, may arise from a benign papilloma, inverted follicular keratosis, actinic keratosis, or malignant squamous cell carcinoma. JJ Kanski (1995) Clinical Ophthalmology

15 Pyogenic granuloma Misnamed Not pyogenic (no pus) Not granulomatous inflammation Vascular proliferation, often associated with conjunctival wound healing May be arrested early stage of wound healing

16 Melanocytic Nevus (mole) Benign proliferation of Congenital or acquired Life cycle: Junctional within stratum basale, young, dark, flat Compound descending partially into dermis, middleaged, still pigmented, domed Intradermal completely below the epidermis, old, domed, often depigmented melanocytes AAO (1998) Basic & Clinical Science Course

17 Congenital Nevus AAO (1998) Basic & Clinical Science Course

18 Giant Hairy Nevus Courtesy Thomas J. Joly, MD, PhD

19 Junctional Nevus JJ Kanski (1995) Clinical Ophthalmology

20 Compound Nevus

21 Intradermal Nevus (mole) Courtesy Thomas J. Joly, MD, PhD

22 Xanthelasma Lipid and cholesterol deposits within dermal histiocytes Sometimes associated with hypercholesterolemia or lipoprotein abnormalities

23 Xanthoma Lipid and cholesterol deposits within histiocytes deep to dermis Associated with xanthogranulomatous disease

24 Malignant Neoplasia of Epithelial Origin Hallmarks of malignancy: Ulceration Destruction of normal architecture Non-tender Induration Irregular, asymmetric Telangiectasia Pearly borders

25 Actinic Keratosis Pre-malignant condition (squamous cell CA) Dysplasia, dyskeratosis, hyperkeratosis, elastosis, chronic inflammation AAO (1998) Basic & Clinical Science Course

26 Keratoacanthoma (pseudoepitheliomatous hyperplasia) Rapidly growing epithelial hyperplasia, with hyperkeratosis and reactive inflammation May be incited by trauma, inflammation or infection Generally considered a low-grade form of squamous cell carcinoma, or pre-malignancy JB Crawford (1981) Duane s Clinical Ophthalmology

27 Basal Cell Carcinoma Invasive, non-metastasizing nests of basal cells Pearly borders, telangiectasia, ulceration, lash loss Commonly on lower lid, medial canthus Types Nodular Ulcerative (rodent ulcer) Cystic Morpheaform (sclerosing) Pigmented JJ Kanski (1995) Clinical Ophthalmology

28 Nodular Basal Cell Carcinoma AAO (1998) Basic & Clinical Science Course

29 Pigmented Basal Cell Carcinoma JB Crawford (1981) Duane s Clinical Ophthalmology

30 Cystic Basal Cell Carcinoma JB Crawford (1981) Duane s Clinical Ophthalmology

31 Morpheaform Basal Cell Carcinoma AAO (1998) Basic & Clinical Science Course

32 Squamous Cell Carcinoma Invasive & metastasizing nests of spinosum or granulosum cells with keratin pearls Ulceration develops under keratin crust Much less common than basal cell cancer JJ Kanski (1995) Clinical Ophthalmology AAO (1998) Basic & Clinical Science Course

33 Squamous Cell Carcinoma conjunctival Courtesy Thomas J. Joly, MD, PhD

34 Lentigo Maligna (Hutchinson s melanotic freckle) Premalignant proliferation of melanocytes Melanoma may form in up to 50% Variable light brown pigmentation JA Nerad, (2001) Oculoplastic Surgery

35 Melanoma Invasive, metastazing melanocyte proliferation Hallmarks: Heterochromia, >10mm, change Types Superficial spreading: 80% of cutaneous melanomas Nodular: most common eyelid Lentigo maligna melanoma SL Robbins et al. (1984) Pathologic Basis of Disease

36 Neoplasia of Adnexal Origin

37 Apocrine hidrocystoma (cyst of Moll, sudoriferous cyst) Blockage of an apocrine sudoriferous gland of Moll resulting in sub-epidermal cyst Usually solitary Cystadenoma is a benign proliferation of multiple cysts

38 Apocrine cystadenoma

39 Eccrine hidrocystoma Cystic benign hyperplasia of eccrine glands JA Nerad, (2001) Oculoplastic Surgery

40 Syringoma Benign adenoma of eccrine sweat glands Arise in dermis Grow premenstrually, in pregnancy, with estrogen therapy FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery

41 Trichoepithelioma Benign hamartoma of hair follicle Appear as small white papule within lashes Hereditary (multiple) or nonhereditary (solitary)

42 Pilomatrixoma (calcifying epithelioma of Malherbe) Benign hamartoma of hair follicle producing hair shaft protein, with calcifications Deep, hard nodule, commonly in children Associated w/ Gardner s Syndrome (colon polyps) Courtesy Thomas J. Joly, MD, PhD

43 Epidermal inclusion cyst Cyst of sequestered, degenerated keratin from a follicular infundibulum Surface pore Often misnamed sebaceous cyst not sebaceous AAO (1998) Basic & Clinical Science Course

44 Milia Cyst of sequestered, degenerated keratin from a follicular infundibulum, smaller than epithelial inclusion cyst Primary, newborn, or secondary to processes stimulating epithelial proliferation dermabrasion, injury FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery

45 Sebaceous Hyperplasia Benign sebaceous gland proliferation Shiny, indurated papules w/ umbilication Skin thickened on cheek, nose, forehead

46 Comedone (blackhead) Sequestered sebaceous secretions Gland orifice blocked with dried, blackened secretions FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery

47 Hordeolum (stye) Acute staphylococcal infection of a gland of Moll or Zeiss (external hordeolum) or Meibomian gland (internal hordeolum) JJ Kanski (1995) Clinical Ophthalmology

48 Chalazion Chronic, non-infected inflammatory nodule due to Meibomian blockage and secretion backup into surrounding tissue Can drain anteriorly or posteriorly JJ Kanski (1995) Clinical Ophthalmology Redatlas.com

49 Sebaceous Carcinoma Adenocarcinoma of Meibomian or Zeis glands Can mimic chronic chalazion or blepharitis Pagetoid spread Metastasis JB Crawford (1981) Duane s Clinical Ophthalmology

50 Classify lid lesions as: Summary Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma

51 Summary Most common Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma

52 Summary Most dangerous Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma

53 Summary Strongly recommend treatment Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma

54 Treatment Available Summary Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma

55 Thank You

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